procedure!

It turns out that the man with the huge pleural effusion and swollen abdomen does not have cancer, just heart failure and cirrhosis. After some hefty doses of lasix and a successful thoracocentesis, he is feeling and looking much better, except for his belly, which is still huge. Now, some doctors might send him home. But not us. The fearless teaching doctors and students on the teaching service see a chance for a procedure: paracentesis!

It tells you something about the incidence of cirrhosis in our patient population that both the intern and the resident are “signed off” on paracentesis. So, that means I can do it! My cup runneth over. Week after next I’ll be on a semi-surgical service (OB), and here we are, after I’d given up hope of getting to do anything interesting on internal medicine.

 

too good to be true

I might have known it. After all that excitement, ultrasound showed not enough fluid to be worth tapping.

Before we went down to see, the resident wanted me to recite all the steps in the procedure, which I mostly knew, except for saying that I would put the big catheter-needle “straight in,” which I meant as opposed to slanted, but she strongly objected to the suggestion of putting it in fast. Some other residents had stopped by, and they all started quizzing me about complications (peritonitis, ruptured intestine, death, etc), and swapping their horror stories of procedures gone wrong, till I was completely scared, too scared to even say I didn’t want to do it anymore. How am I ever going to do surgery?

So I’m not too disappointed. But one of the other interns has developed a strong desire to do procedures, and we have another patient whom we have better reason to believe has ascites. I’m not asking to do anything with him, as he is already very angry with the hospital in general, and already complaining of severe pain from the swelling; so he’s guaranteed to be a very difficult stick, and I would hate to be involved if any complications did happen. So this afternoon should be interesting.

 

doctor as executioner

You know a society is in trouble when ancient Greek ethics start to look good compared to modern ones. Ancient Greece was, after all, a land that idolized warriors, whose favorite piece of literature spends thousands of lines describing the deaths of warriors (“he fell to the ground and his armor clattered around him”), which allowed infanticide, where homosexuality was an accepted institution, whose pantheon consisted of all-too-human lustful, violent, treacherous gods – and yet they had better medical ethics than modern America. Hippocrates was an unenlightened pagan, who swore by the imaginary Aesculapius and Apollo, and yet I’d rather take him for a mentor than many Oregon doctors: “I swear . . . I will neither give a deadly drug to anyone who asks for it, nor will I make a suggestion to this effect.”   

Yesterday the Supreme Court, in a 6-3 decision (Roberts, hurrah! and Scalia and Thomas dissenting) refused to allow the US Attorney General the authority to prosecute Oregon doctors who assist in suicides under an Oregon law. (Opinion here, for anyone who wants to slug through the twisted reasoning.) So apparently the AG can prosecute California cancer patients for using marijuana, per that state’s statutes, but cannot prosecute Oregon doctors for, essentially, murder, when it is justified by that state’s laws. Does nobody else see a problem here?! The decision is being hailed by “death with dignity” advocates who hope to extend this type of law into other states. Vermont, to nobody’s surprise, is high on the list.

The resident has cleverly disposed of all of our patients before we start call, and rounds aren’t for a while yet, so we can examine the multitudinous fallacies behind the Oregon law. Essentially, doctors can prescribe fatal doses of barbiturates to patients who are determined to have a “terminal” condition (expected to die within 6 months), and who are judged to be competent to make decisions, and who make two written requests fifteen days aparts.

 

minor excitements

For being a third-year student, I have been pimped remarkably little, compared to some of my classmates. I don’t count it when it’s just me and the attending or resident; that’s plain teaching, to ask questions, see how much I know, then explain what I don’t. I only mind it the slightest bit when it’s on rounds, and everyone else is listening with interest to see how well or how badly you’ll do.

Attendings, the senior doctors who supervise the residents – usually switch off every two weeks, because they’re on call continually. Not that residents like to call the attending in the middle of the night, but it can happen, with no weekends off. So our new attending is the chief of hematology/oncology at the VA; nice older gentleman, stoop-shouldered from peering into microscopes, with a harmless manner, but very sharp mind. He seems to run rounds very fast, which is fine by us. Today, being an on-call day, we didn’t have any new patients to discuss in detail, so he took us around to his office, which is a tiny lab room stuffed with refrigerators, hoods, microscopes, and jugs of reagent, and stained papers on top of everything.

He invited me and the other medical student to pick one to be quizzed today, so I took it, on the principle of getting things over with quickly. We sat down on opposite sides of a demonstration microscope – two sets of eyepieces, so he can find things and show them to me at the same time. “Healthy elderly gentleman, pre-op CBC before a hernia repair, found to have a white cell count of 50,000 [normal is less than 10,000]. Looking at his peripheral [blood] smear. . .” I think he forgot that this exact same case had been part of the heme/onc quiz yesterday. The patient of course has CLL, chronic lymphocytic leukemia, an indolent, slowly progressive, incurable leukemia most common in the elderly. And I had been expecting some detailed questions for the quiz yesterday, so I had studied it all: prognosis (10+yr life expectancy), cure rate (none), complications (blast crisis, where the CLL suddenly turns into AML, acute myelocytic leukemia, and the patient dies in weeks), and molecular diagnosis (look for CD5 and CD23 markers, which will distinguish CLL from mantle cell lymphoma, which has CD5 but not CD23).

The attending of course was delighted with me. We had our own private conversation, as everyone else had forgotten about the markers. So all morning the residents have been teasing me about showing off in heme/onc, which isn’t even a field that I’m interested in. I haven’t yet managed to persuade them that if he had asked about anything else at all (AML, ALL, CML) I would have been completely lost.

We had very few patients until this morning, except now along with the snow outside we’re getting snowed with patients too. My resident, in spite of her grumpy manner, actually is very kind about picking up overworked residents’ patients, with the result that she gets herself overworked eventually. Right now we’re clearing house for the other teams, and the ICU too, by letting them dump all over us. So hopefully we’ll pick up a few interesting patients somewhere in there.

The other day I was checking on one of my patients, who had told me on admission that he was an ordained minister in one of Pentecostal-type churches. I suppose it says I pay too much attention to appearances; I had a hard time giving much credence to an overweight, stubbly man in yellow pajamas and a nasal cannula. Then that morning he asked suddenly if I was Coptic. I was dumbfounded. How did he know about the Copts? He had met a priest in a doctor’s office once. Then he began telling me about how wonderful Clement of Alexandria was, and Nicholas of Myra, and although he didn’t recognize Athanasius’ name, he did know about the Council of Nicea, and the Creed, and the importance of defeating Arius’ heresy. He started calling me “sis,” for “sister,” which is a little familiar for my taste, but who cares. Anyone who knows about Clement and Nicholas can call me “sis” any day.

 

cancer service

That’s what we’re calling ourselves now. In the course of four hours this afternoon the resident accepted 8 patients, which makes 14 altogether now. Two of them appear to have cancer, and that’s without shuffling to look at the last two or three. I’m waiting for the next one to come up to the floor from the ER, so I’m not wasting time yet. I did have several books to study, expecting a quiet day like last time, but I can’t concentrate like this.

I hate this kind of statement: “Patient quit smoking 20 years ago.” Anybody getting cancer is awful, even if they’re still smoking as you speak, but when people quit, especially when they quit a long time ago, that’s really depressing. They thought they had safeguarded themselves, and it didn’t work. The one patient today actually had adrenal cancer, resected five years ago, and stopped being followed up, then appeared several months later with nodules all over his lungs, and something in his thyroid. So is this recurrence of the first cancer, new lung cancer, or metastatic thyroid cancer? More news tomorrow, I guess. I also hate it when a healthy-looking person is proven to have metastatic cancer, which means they’re going to die in a few months and there’s next to chance of stopping it. I can’t really believe that it’s that bad, already.

The other guy presents with sudden onset of congestive heart failure, severe dyspnea, and one-sided pleural effusion, as well as profound hyponatremia (low sodium). At first glance that sounds like plain old CHF, but with eyes sharpened by numerous cancer discoveries over the last week, the resident noted that hyponatremia is caused by some kinds of lung cancer, and one-sided pleural effusions are often malignant. So that makes another cancer, and another thoracocentesis as soon as the beeper from the ER stops going off.

Last count it’s fifteen, and the phone just rang again. Boy am I glad I already got permission to leave early to study for the test tomorrow. I’ve worn out my enthusiasm, at least for this call day. And two people asked how old I am today. Do I look too young for this chaos, or what?

 

somebody’s panicked

My favorite part about the Alito nomination has been watching the liberals tear their hair out in fear that they will actually lose that cherished constitutional right, to kill babies, as established in Roe v. Wade. Personally I didn’t think there was much chance of it happening soon, but the more frantic editorials like Ellen Goodman’s that I see, the more maps showing what states are likely to outlaw abortion if they can, the more hopeful I become.

(Ellen Goodman, by the way, is complaining that not enough doctors in Midwestern states like South Dakota want to perform abortions already. Here we see the true hypocrisy of these liberal feminists: Not only are they willing to sacrifice women’s mental and emotional health in order to make themselves more like men who can’t bear children, but they care nothing for the right of doctors to refuse to perform certain procedures. They don’t really want freedom to choose; they want their own choices imposed on everyone. Check out this World Magazine article for documentation of the lasting damage abortion does to women who “choose” it.)

We only have a few patients and I already wrote my notes, so I could go on here for hours about the horror of the state-authorized murder which has covered this land in blood for thirty years already. Even the slightest knowledge of embryology shows the falsehood of saying these innocent children are not human. At 20 days old, before most women realize they’re pregnant, the baby’s heart has begun beating. Within a few weeks, their hands and feet are forming. Click here to see pictures of human development in utero. Then, if you have the stomach for it, click here and scroll down to the bottom of the page for links to pictures of aborted babies. It doesn’t matter that they’re only the size of a coin; they’re humans, distinct genetic and spiritual entities, and they’ve been murdered.

It is the height of irony that our society now cares more for the comfort of animals meant to be slaughtered for food than we do for the lives of our own children. How fitting that the West is about to be overrun by the Islamic culture which, whatever its other faults, at least values children.

If only, if only these liberals’ fears could come true. If only God would grant us to end this massacre of innocents.

 

speaking of politics

Thanks to Red State Moron for typing up this editorial from yesterday’s Wall Street Journal regarding the politicking of the New England Journal of Medicine, and their shabby attempts to join in the pile-up on Merck. Basically, the NEJM accused Merck of keeping back data from a study they published in the Journal. Actually, that information was released to the public early on by Merck, and only not published because the three heart events referred to had occurred after the pre-specified end of the study. Science doesn’t allow for playing with the rules. Studies are designed within a timeframe; you’re not allowed to add in either good or bad things that happen after the end of that frame, because that’s the beginning of monkeying with the data. NEJM definitely should know this, it’s taught in college-level intro to research classes. But it’s politically correct to throw mud at Merck these days, so God forbid the NEJM shouldn’t join in the mudslinging. Honest publication of real research is beginning to be too passé for them. After all, this is the journal that publishes articles from China defending the one-child policy and forced abortions, and articles from Holland defending euthanasia of handicapped children.

I’ve decided, I’m too disgusted with NEJM’s wacky editorial policies to renew my subscription. I thought I’d be all grownup and responsible doctory by subscribing to the famous journal, but no. It’s not good for my heart to jump into tachycardia and possibly arrhythmias every time I look at their table of contents; especially it’s not good for my wallet to pay to support this stuff. So from now on I’ll just look at it in the library.

 

holding hands

This morning, driving in, I was very puzzled. Where was all the usual rush-hour traffic? Finally I realized that most people don’t routinely come in to work on Saturday morning.

Yesterday afternoon one of the elderly patients belonging to the other half of our team became very agitated; his doctor was post-call, so my resident offered to handle the situation, which she did by promising the agitated nurses to send her medical student up to investigate. I didn’t hear that; she told me that the wife needed her hand held. So I went and took the wife down the hall to a quiet area and listened to her talk about her husband. Eventually the resident arrived, and suggested that if the patient was upset because he felt he was falling out of his chair, in spite of lying flat in bed, I should go look in his ears by way of assessing the situation. She talked to the wife, ordered some meclizine (like phenergan, supposed to help with dizziness), and went back downstairs.

This left me with the patient and nurses. The poor old man had either dementia or severe TIAs (transient ischemic attacks/ministrokes), we’re not sure which yet, and every two minutes he would start yelling that he was falling. His wife was holding his hand, and I was holding the other hand and trying to calm him down, because he was shouting loud enough to disturb the whole unit, and the nurses were not happy. The following conversation ensued:

Pt: AAAAHHH!! Push me back in the chair!

Me: You’re in the bed; here, feel it; you’re lying flat in bed.

Pt: I don’t feel like it.

Me: It’s ok, you’re in bed. . . . .

Pt: AAAAAHHH!! Push me back in the chair!

Me: You’re here in bad, you’re lying down flat.

Pt: I don’t feel like it.

[repeat ad lib]

Wife: We’ve already had this conversation.

And the nurse kept walking in and out, between trying to dispense medicines to everyone else, to observe that this didn’t look like any TIA or dementia she’d ever seen, and the wife saying he was having a seizure. Eventually they got to me, and I paged the residents until they prescribed some ativan, at which point I escaped from that floor.

When I got downstairs, all of the team was busy setting up for a thoracocentesis (needle and catheter in pleural space) for one of our sister team’s patients with a large pleural effusion. My resident had never done one, and she needed to be observed. So there was her, the intern, the chief resident, and the resident in charge of the patient, plus me. While they were setting up, I managed to absent-mindedly touch the sterile field. So I figured the safest place for me would be holding the guy’s hand.

To distract him while they were putting the lidocaine (local anesthetic), I asked where and when he had served. He had lost his leg from a battle wound in Korea. So we talked some about Korea. I felt ashamed; the only thing I know about Korea is “Frozen Chosin,” the winter retreat, and that Macarthur wanted to drop a nuclear bomb on the border with China, and Truman wouldn’t let him.

Well, the resident had to try literally a dozen times, in about six different locations, which took a whole hour; so the poor man was screaming and squeezing my hand, and my arm, and eventually I figured out he was trying to hold onto as much of me as he could reach, besides winking at me every five minutes. It took me about half an hour to realize what he was up to. And by then I figured, if he was enjoying any aspect of the proceedings, in between screaming, it wasn’t really harming me if he held my arm too. But now I know why they say to stay away from the old men in the VA.

I was not happy with the procedure, though. I had to make myself go through the whole differential diagnosis for a one-sided pleural effusion, which includes cancer and TB, to make myself not try to make them stop; not that they would have listened to me.

Well, on a different topic: one thing that I’ve learned this rotation is not to put much store in first impressions. I thought my resident would be awful, those first few days; but now I really like her. From the way she talks, you would think she would be a very rough doctor, but she isn’t. When she’s talking to patients, she’s cheerful and calm and careful, and they all like her. And then one of the other medical students, whom I haven’t known much till now; just from hearing her in class, I would think she was very brash and tough and unpleasant. But the other day (being very enthusiastic, almost a gunner) she took me along to see a man with advanced cirrhosis, and her manner with him was impressive. She was so nice, and clearly had established a good relationship with him in just a few days. Both of these women are going to be very good doctors, and their patients already love them. So I should stop jumping to conclusions.

 

dangers of residency

One learns so much by sitting in the corner and listening to the residents gossiping. My resident is a great talker, and her friends keep stopping by to talk.

The post-call team, here overnight from Friday, just signed out to us. They were warned to be careful driving home, because just last week one of the residents at this program crashed his car driving home after work. The senior resident who just left is the despair of the other seniors, because he works ridiculous hours, coming in at 4 or 5 in the morning, staying till midnight or later, being obsessive over his patients. Everyone else seems to be continually conspiring to get him out of the hospital. This program is in trouble with the ACGME (accrediting board) because of residents working more than 80 hrs/week. This particular resident lies outrageously about the hours he works. The other residents feel that they’re more honest because they only shave two or three hours per day off their reported hours. They’re in two minds about what strategy to adopt towards the reporting sheets. If they don’t tell the truth about the hours they’re working, no one will ever be able to help them. But if they tell the truth, their program will be penalized, and may even lose its accreditation, in which case they will be forced to accept transfers into any random program that will take them.

Yesterday the attending and my resident spent fifteen minutes trading stories about residents killed or injured driving home after late hours.

There are several patients on our service with fairly important surgical issues, but we can’t find a surgeon to take them. Some of the surgies are complex or risky, and no one at this stupid VA hospital does them, so we have to get them transferred, either across town, or across the state. That’s the other thing my resident does in her spare time, tell horror stories about critically ill patients she’s had, who needed either emergency neurosurgery, or emergency cardiac surgery, or just plain surgical attention (like the guy bleeding himself dry all over the sheets, who turned out to have just one small vessel that had come untied), while she frantically tried to persuade somebody to stop protecting themselves, and come take care of the patient. The attending did explain, though, that the reason surgeons are so terribly reluctant to help with someone else’s case (“it’s their mess, their complication, they can come take care of it”) is because in lawsuits, everyone whose name appears on the chart will get sued. So if the first surgeon did something wrong, whoever tries to fix it for him is liable to get themselves sued for their helpfulness and generosity. Internists don’t have that problem, because they don’t yet commonly get sued for surgical errors.

And then all the stories about nasty attendings, and troublesome hospitals. A couple months ago I wasn’t sure what to look for when I go interviewing for residencies. Now I guess I know: make a list of what I dislike at the VA, and try to make sure the residency I choose has as little of that as possible.

We’ve only gotten two patients so far today, but I’m not allowed to comment on that out loud because it’s supposed to be unlucky. Having done all my studying, I guess I’ll go back to knitting and reading my medieval historical fiction. Which is depressing, because I love the characters, but I know what happens to them, and there’s no way to fix it, no hope that they won’t all die tragically.

 

quiet night

I cannot believe it: only two patients all day, and one of them a transfer from the ICU. We finished the only admission work before noon. There is one other patient of ours in the ICU, the poor guy who went into sepsis from a kidney infection, but his blood sugars are still way out of control, and neither the ICU residents nor our team want to take him off the insulin drip yet.

Things are probably quiet because this floor is so packed, there are no telemetry beds left. Our one admission took the last one, and that was available only after the resident shuffled through the whole census of patients, and found one person who could be taken off the tele monitor. So there are probably some people in the ER who have been transferred to a different hospital, and a couple heart patients put in the ICU. But for us, it makes a rather boring day.

The only excitement was the computer eating my history and physical of that one patient, so that I had to type the whole thing twice, and now none of the computers will print it – arg! But it was ok: his main complaint was shortness of breath, so by the time I had the H&P saved, I’d got the differential for shortness of breath fairly thoroughly memorized. The resident had quizzed me on it, and kept asking “what else,” till I was quite out of ideas, having added malignancy and lupus and sarcoidosis and Wegener’s granulomatosis to the more common heart failure and asthma and COPD and pneumonia. It turned out the answer she wanted was, nothing else!

The only other interest in the day has been watching the resident try to manage the intern. I’m beginning to think the intern is not just shy, but pathological. She has a very hard time making decisions, is constantly referring back to the resident, or calling the nurses back after thinking for five minutes about what should be a snap decision. And this makes me bother the resident too, because I can’t ask the intern questions. She’ll give the short, easy answer, and not go into all the differential, and possibilities, and considerations that the resident does. Or if it’s a question about how to maneuver to help a patient, her answer is always, I don’t know. So I always have to ask the resident everything. And it’s not like she’s terribly young, she’s married and has children, though she doesn’t look it. I’m scared to think what her second year will be like, when she’ll be in charge of an intern. Unless the intern is gifted with tremendous strength of character, to decide things on his own early on, it will be a mess. I’m thinking by the end of this month the resident will be so concerned she might take steps to get the authorities to pay attention.

God, please help me to be a good doctor, please help me learn enough to be responsible!